Managing Behavioral Health Risks in Older Adults

Dear Fellow Clinical Gerontologists:

Managing behavioral health risks is an important element of high-quality clinical care for older adults. In this issue, we present papers that address different aspects of risk in behavioral health care.

We begin with two studies focusing on risk issues related to caregivers. Our first paper provides a novel and insightful review of 14 studies focusing on risks when providing care to a parent with a history of mistreatment of the caregiver when the caregiver was a child (Kong, Kunze, Goldberg, & Schroepfer, 2021). Studies reviewed find a higher risk of negative mental health outcomes for caregivers with such histories, yet complex factors need to be considered including understanding the nature of the current relationship, ensuring a sense of choice for the caregiver, and providing opportunities for growth and reconciliation. Our second caregiver-related article focuses on managing driving risk in individuals with dementia. Caregiver (N = 179) ratings of driving quality and memory concerns combined were a predictor of road test failure (Barco et al., 2021), emphasizing the value of working closely with family to understand driving risks.

Our next studies consider suicide prevention in high-risk populations. Rates of suicide are rising in rural areas, where farming and agriculture are prevalent occupations. In an innovative study of descriptive and predictive factors of 2,106 older farmers who completed suicide, most were white males and were more likely to have physical problems (Bower & Emerson, 2021). The authors call for greater attention to screening and mental health care in rural areas. Another population at heightened risk for suicide are older adults transitioning from a skilled nursing facility to home. In an important intervention study, 62 older adults who participated in “SAVE-CLC” were more likely to be screened and to have a first mental health visit compared to matched controls (Hilgeman et al., 2021). This intervention within the U.S. Veterans Health System provides telephone-based screening, support, and care coordination.

Falls are another type of risk for older adults and one in which behavioral health plays an important role in both assessment and management. Two studies in this issue focus on fall risk assessment. Meimandi and colleagues found the 16-item Falls Efficacy Scales (FES) to have good sensitivity and specificity in predicting falls in 100 older adults in long-term care, better than a single item (Meimandi, Fadavi-Ghaffari, Taghizadeh, Azad, & Lajevardi, 2020). Extending this work, Thiamwong and colleagues compared subjective and objective fall risk measures in 433 older adults, finding only 21% had fall risk perceptions that matched their risk (Thiamwong, Ng, Kwan, & Suwanno, 2021).

Next, we move to conditions and experiences that may bring older adults to the attention of behavioral healthcare professionals as well as adult protective service professionals. Hoarding disorder is one such condition that, when severe, may lead to both behavioral health interventions and adult protective service involvement. In an intriguing study of 49 adults in treatment for hoarding disorder, participants sorted home items for being discarded for 1–15 minutes, rating pre- and post-task emotions (Dozier et al., 2020). Fear, while the most commonly experienced emotion was not highly endorsed. The authors conclude that anxiety and fear may not be universal drivers of hoarding across the lifespan. We look forward to continued work from this group in establishing etiological mechanisms for hoarding and effective treatments.

Another all too common issue that brings older adults to the attention of behavioral health care and adult protective service professionals is financial exploitation and fraud. In a unique investigation of this issue in 251 Chinese older adults, fear of aging was found to be associated with vulnerability to fraud as moderated by a lower sense of self-control (Shao, Yang, Lei, Li, & Zhang, 2019), emphasizing the importance of interpersonal factors in managing risk. Three papers in this issue continue to expand our assessment toolbox for mitigating financial risk. The first of these focuses on identifying those most at risk once brought to the attention of adult protective services. In this study, four items from the Financial Decision Tracker had a moderate effect size for differentiating adults at highest risk for exploitation amongst a group of 445 older adults under protective service investigation (Lichtenberg et al., 2021). These items include those related to financial well-being, impact on finances, and “who benefits” from the financial decision along with the item “was this your idea or did someone suggest it or accompany you.” While the Financial Decision Tracker may be particularly useful for sorting through exploitation for those with identified exposure, the Financial Exploitation Vulnerability Scale may be useful in identifying those at risk. The next papers present evidence for the validity of the Financial Exploitation Vulnerability Scale (Lichtenberg, Tocco, Moray, & Hall, 2021) and for a 9-item short form (Moray & Lichtenberg, 2020) which assesses financial exploitation vulnerability. Both these tools should be helpful to mental health and adult protective services professionals in the field.

We thank the authors of these studies for their ongoing work to characterize who is at risk, to provide useful approaches to assessment, and to develop effective interventions.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This material is the result of work supported with resources and the use of facilities at the VA Boston Healthcare System. The contents do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.